FORM NO.

15D
[See rule 29B]

Application by a person other than a banking company for a certificate under section
195(3)
of the Income-tax Act, 1961, for receipt of sums other than interest and dividends
without deduction of tax
To
The Assessing Officer,

Sir,
I, _________________ , being the principal officer of __________________ we _____________ [name of the
person, firm or company entitled to receive sums other than interest and dividends] do hereby declare :

(a) that I/ _____________ [name of the firm, company, etc.] am/is a non-resident assessee (not being a banking
company) carrying on business/profession in India through a branch(es) by name(s) _____________ having
office(s) at _____________ ;
(b) that my head office/the head office of _________________ [name of the firm, company, etc.] is situated at
[name of the place and country]
(c) that I/ ___________________ [name of the firm, company, etc.] am/is entitled to receive income (other than
dividends and interest) chargeable under the provisions of the Income-tax Act, 1961, during the financial
year;
(d) that I/ _________________________ [name of the firm, company, etc.] fulfil(s) all the conditions laid down
in rule 29B of the Income-tax Rules, 1962.
I, therefore, request that a certificate may be issued authorising me/ ________________________ [name of the
firm, company, etc.] to receive income other than interest or dividends without deduction of tax under sub-
section (1) of section 195 of the Income-tax Act, 1961, during the financial year

I hereby declare that what is stated in this application is correct.

Date ______________
Signature

Address

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